Murat Kapkac

p53 and Ki‐67 Expression as Prognostic Factors in Cystosarcoma Phyllodes

We have reviewed the histopathological, clinical outcome and immunohistochemical status in 21 women with cystosarcoma phyllodes (CSP) tumors of the breast. We assessed 12 tumors as histopathologically benign and 9 tumors as malignant. The median patient ages in benign and malignant CSP tumors were 39.6 and 45.4 years of age, respectively. The stromal cellularity, stromal cellular atypism, high mitotic activity, atypic mitoses, stromal overgrowth, infiltrative tumor contour, and heterologous stromal elements were significant features of the malignant CSP tumors. Benign CSP tumors were predominantly of fibroadenomatous architecture with cellular stroma (mild or moderate) and some distortion and elongation of glandular elements. Five malignant CSP tumors were stained positively with p53, and 6 malignant CSP tumors were stained immunohistochemically with Ki‐67. All benign CSP tumors were negatively stained for p53 and Ki‐67. The patients with benign CSP tumors were treated with local excision (n = 11) and with subcutaneous mastectomy (n = 1). Malignant CSP tumors were treated with wide local excision (n = 1), partial mastectomy (n = 1), simple mastectomy (n = 2), and modified radical mastectomy (n = 5). Two patients with a high mitotic rate and high values of p53 and Ki‐67 received additional radiotherapy and chemotherapy. One case had liver metastasis. This tumor had high mitotic figures, stromal overgrowth, severe stromal cellularity, and 20% Ki‐67 and mild p53 positivity. We suggest that p53 and Ki‐67 can play an important role in predicting prognosis and yielding additional therapy besides conventional prognostic factors in the treatment of the CSP patients.

The use of periareolar intradermal Tc-99m tin colloid and peritumoral intraparenchymal isosulfan blue dye injections for determination of the sentinel lymph node.

Purpose: The purpose of the present study was to evaluate the use of lymphoscintigraphy, blue dye, and gamma probe detection methods for determination of the sentinel lymph node (SLN) using both periareolar intradermal injection of Tc-99m tin colloid and peritumoral intraparenchymal injection of isosulfan blue dye. Methods: One hundred patients with T1–2 breast cancer and clinically negative nodes were enrolled in the present study. The study was composed of 2 groups. Backup axillary lymph node dissection (ALND) was mandatory in group 1 (20 patients) regardless of their lymph node status. In group 2 (80 patients), complete ALND was performed when intraoperative frozen section analysis of SLN revealed metastases. Otherwise, only SLN biopsy was performed without ALND. One day before surgery, Tc-99m tin colloid was injected at 4 periareolar sites intradermally. Lymphoscintigraphy was performed 1 to 2 hours after injection of the radiocolloid. Twenty minutes before surgery, isosulfan blue dye was injected into parenchyma surrounding the tumor or the biopsy cavity. Results: The detection rates of SLN and false-negative rate of lymphoscintigraphy, blue dye, and gamma probe detection were 85%, 95% 100%, and 0% in group 1, 91%, 87%, and 95% in group 2, respectively. Detection rate by the combination of blue dye and radio tracer was 98%. Conclusions: According to the results of our study, we conclude that perioareolar intradermal injection of Tc-99m tin colloid combined with peritumoral intraparenchymal injection of blue dye is an accurate and easy method of locating the sentinel node with very high detection rates. It is recommended that the combination of all methods such as lymphoscintigraphy, blue dye, and gamma probe application will increase the success rate of SLN detection in patients with breast cancer.

Fiber enriched diets and radiation induced injury of the gut

The aim of this study was to evaluate the effect of fiber-enriched defined formula diets (DFDs) on radiation-induced enteropathy. Forty-five male Sprague-Dawley rats were assigned randomly after abdominal irradiation to one of three groups (15 in each group): a fiber-free DFD group, a non-soluble fiber-enriched DFD group, and a soluble fiber-enriched DFD group. They kept their diets respectively for seven days. On day eight, the mesenteric lymph nodes were harvested for bacterial translocation, and segments of jejenum and colon were sampled for microscopic examination. The rats in the fiber-enriched DFD groups lost significantly less body weight than the rats in the fiber-free DFD group. The intestinal structure was the worst in the fiber-free DFD group, intermediate in the soluble fiber-enriched DFD group, and the best in the non-soluble fiber-enriched DFD group with significantly higher measures of villous height and jejunal mucosal thickness. These findings suggest that fiber-enriched DFD may effectively protect intestinal structure against radiation-induced damage by improving mucosal integrity.

Effects of Somatostatin Analogues and Vitamin C on Bacterial Translocation in an Experimental Intestinal Obstruction Model of Rats

The passage of viable endogenous bacteria and their products across the intact intestinal mucosal barrier, disseminating to the mesenteric lymph nodes, peritoneal cavity, spleen, liver, and circulation, is defined as bacterial translocation. Intestinal obstruction induces bacterial translocation due to mucosal disruption, motility dysfunction, and increased intestinal volume, leading to bacterial overgrowth. In a rat model of intestinal obstruction, the effects of both high-dose vitamin C (350 microg/kg), an antioxidant agent known to have a cytoprotective effect in ischemia-reperfusion injury, and somatostatin (20 microg/kg), a gastrointestinal antisecretory agent, in preventing bacterial translocation were studied. Both intestinal and liver samples from the rats was observed, and it was found that the rate of bacterial translocation was 100% in the control group, and only 43% for the rats who were given intraperitoneal vitamin C and somatostatin. The difference was statistically significant. In conclusion, we are convinced that vitamin C and somatostatin analogues may have protective effects against bacterial translocation in mechanical bowel obstruction.

Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies

Background: One of the most important factors in breast cancer (BC) mortality is treatment delay. The primary goal of this survey was to identify factors affecting the total delay time (TDT) in Turkish BC patients. Methods: A total of 1031 patients with BC were surveyed using a uniform questionnaire. The time between discovering the first symptom and signing up for the first medical visit (patient delay time; PDT) and the time between the first medical visit and the start of therapy (system delay time; SDT) were modelled separately with multilevel regression. Results: The mean PDT, SDT and TDT were 4.8, 10.5 and 13.8 weeks, respectively. In all, 42% of the patients had a TDT >12 weeks. Longer PDT was significantly correlated with disregarding symptoms and having age of between 30 and 39 years. Shorter PDT was characteristic of patients who: had stronger self-examination habits, received more support from family and friends and had at least secondary education. Predictors of longer SDT included disregard of symptoms, distrust in success of therapy and medical system and having PDT in excess of 4 weeks. Shorter SDT was linked to the age of >60 years. Patients who were diagnosed during a periodic check-up or opportunistic mammography displayed shorter SDT compared with those who had symptomatic BC and their first medical examination was by a surgeon. Conclusion: TDT in Turkey is long and remains a major problem. Delays can be reduced by increasing BC awareness, implementing organized population-based screening programmes and founding cancer centres.

Problematic aspects of sentinel lymph node biopsy and its relation to previous excisional biopsy in breast cancer.

Purpose: The aim of the study is to review problematic aspects of sentinel lymph node biopsy (SLNB) and to evaluate the influence of a previous excisional biopsy on these problems. Materials and Methods: A total of 345 patients were evaluated retrospectively, 156 of them had a previous biopsy. Tc-99m tin colloid was injected the day before surgery at 4 quadrants around the areola intradermally. Problems complicating SLNB are reviewed in 3 topics: visualization or gamma probe detection problems, dilated lymphatic channels, and misleading activity accumulation. Results: SLN detection rate and mean sentinel lymph node numbers were as follows in patients with and without biopsy, respectively: 95.5% versus 99.4% and 1.71 ± 0.97 versus 1.70 ± 0.92. Problems complicating the procedure occurred in 20 patients (5.8%). Among these 20 patients, 15 had a prior excisional biopsy, and incisions were located in the upper, outer and periareolar zones. Visualization or gamma probe detection problems occurred in 8 patients. Except for one with faint uptake in a sentinel node, all had a prior biopsy. Lymphatic channel dilatation complicated the procedure in 7 patients. Of these 7 patients, 4 had a previous biopsy. Misleading activity accumulations compromised SLNB in 5 patients, 4 of whom had a prior biopsy. Conclusion: Although SLNB is still applicable with a high success rate in cases with excisional biopsy, a review of problematic aspects of SLNB demonstrated a relation with the presence of a previous biopsy and its localization. The demonstration of nonvisualization preoperatively and the precise localization of atypically located activity accumulation may be helpful in the prevention of potential complications.

The role of breast MRI in planning the surgical treatment of breast cancer

PURPOSE To determine the frequency by which breast magnetic resonance imaging (MRI) provides information that influences the surgical management of patients with breast cancer. MATERIALS AND METHODS From August 2006 to December 2008, contrast-enhanced bilateral breast MRI was performed on 68 patients, all of whom exhibited highly suspicious imaging findings (BI-RADS category 4 or 5). Patients were grouped according to their histopathological diagnosis and type of breast parenchyma. All of the enrolled patients were believed to be candidates for breast conservation on the basis of physical examination, mammography, and ultrasonography. The patients were reevaluated with the MRI examination as to whether they were still candidates for breast conservation therapy. RESULTS The MRI findings changed the previous management plans in 19.1% of the 68 patients. With respect to the surgical approach, no statistically significant difference was observed between the histopathology groups (P = 0.403). In terms of the breast parenchymal pattern, however, surgical planning was changed in 53.8% of the patients who exhibited a dense pattern, which was significantly different from the rates of the other groups (P = 0.006). The sensitivity, specificity, positive predictive value, and negative predictive value of the MRI for additional malignant lesion detection and identification were 85%, 98%, 92%, and 96%, respectively. The agreement test revealed 86% agreement (very good) between the additional findings observed on the MRI and the histopathological results. CONCLUSION If breast-conserving surgery is planned, an MRI should be performed in all women with suspected breast cancer, especially those exhibiting dense or heterogeneously dense breast parenchyma, for which the sensitivity of both ultrasonography and mammography is low.

Fine needle aspiration cytology of glycogen-rich clear cell carcinoma of the breast: review of 37 cases with histologic correlation.

OBJECTIVE To analyze fine-needle aspiration cytology (FNAC) material from 37 cases of breast glycogen-rich clear cell cancer (GRCC) and correlate cytomorphologic features with histologic appearance to determine characteristics of GRCC on FNAC. STUDY DESIGN We reviewed cytologic features of 37 cases of breast GRCC from the archives of Ege University Hospital diagnosed between 1994 and 2006. RESULTS Thirty-seven patients with available aspirate and confirmed GRCC were identified. The female patients ranged from 32 to 81 years (mean 52 years). The initial cytologic diagnoses were adenocarcinoma for 27 and atypical or suspicious for cancer for 10. The cytologic picture was characterized by hypercellular tumor cells in loosely cohesive syncytial groups and some single cells. Most tumor cells had abundant, finely granular eosinophilic cytoplasm or foamy to clear cytoplasm with well-defined cytoplasmic membranes and moderate to marked nuclear pleomorphism with prominent nucleoli. Histologic examination confirmed all cases to be pure GRCC. CONCLUSION Breast GRCC is a rare, distinct category with cytologic features that overlap considerably with those of other carcinomas. Awareness of variability in cytomorphologic appearance of GRCC and routine assessment for glycogen facilitate accurate diagnosis of these lesions by FNAC and enable prompt treatment of these poor-prognosis breast cancers.

p53 protein accumulation and presence of visceral metastasis are independent prognostic factors for survival in patients with metastatic inflammatory breast carcinoma.

Objective: The aim of this study was to determine the markers of prognosis in metastatic inflammatory breast cancer (IBC). Subjects and Methods: The prognostic value of patients’ clinical characteristics and expression of c-erbB-2, p53, Ki-67, ER and PgR were assessed in the 45 patients with IBC who had developed distant metastasis. Immunohistochemical methods were used to detect the expression of c-erbB-2, p53, Ki-67, ER and PgR in surgical resection specimens of the patients’ primary tumor. Results: The median overall survival (OS) measured from the diagnosis of metastatic disease was 23 months. In the univariate analysis, p53 protein accumulation and the presence of visceral metastasis were predictive of poor survival (p = 0.01 and 0.003, respectively). In the multivariate analysis, accumulation of p53 protein and the presence of visceral metastasis correlated with OS (p = 0.02 and 0.008, respectively). Conclusion: In metastatic IBC, accumulation of p53 protein and presence of visceral metastasis are independent prognostic factors for OS. Established prognostic factors in non-IBC patients such as patient age, histologic grade, hormone receptor status and c-erbB-2 status did not have independent significance in IBC in this study.

Signet ring cells in fine needle aspiration cytology of breast carcinomas: review of the cytological findings in ten cases identified by histology

Objective:  To establish whether the presence of signet ring cells (SRCs) in histology sections of breast carcinoma cases was reflected by their presence in fine needle aspiration cytology (FNAC) smears, correlating to the histological type of breast carcinoma.